Getting It From Both Sides: Foundational and Antifoundational Critiques of Psychiatry

Western institutional psychiatry has been the target of numerous social, philosophical, and scientific critiques over the past century, sometimes lumped together as manifestations of antipsychiatry.1 In actuality, psychiatry’s critics have proceeded from 2 widely divergent sets of assumptions, although they have generally reached similar conclusions. Both foundational and antifoundational critiques have had the effect of discrediting and marginalizing psychiatry and of delegitimizing psychiatric diagnosis and nosology.

Foundational and antifoundational philosophies

Foundational philosophies hold that we can reliably describe a coherent, objectively measurable or discernible reality or truth, whether one considers the world as a whole or specific aspects of it, such as the classification of disease. Logical positivism is a specific manifestation of the foundational worldview and regards all genuine knowledge as based on logical inference grounded in observable facts; indeed, only empirically verifiable statements are regarded as meaningful by logical positivists.2

The best-known foundational critique of psychiatric diagnosis comes from Thomas Szasz.1,3 In essence, Szasz argues that we know that real (genuine) disease entails the presence of pathological lesions or abnormal pathophysiology1,2; we know that “diseases” such as schizophrenia do not consistently demonstrate such objectively verifiable abnormalities; therefore, we know that schizophrenia (and similar psychiatric fabrications) cannot be genuine, ontologically real diseases.3

In contrast, antifoundational philosophies and philosophers assert that there are no objectively demonstrable truths; rather, there are only various perspectives or narratives that cannot be privileged as uniquely or objectively true. Although there is no fully satisfactory definition of postmodernism, we consider antifoundational critiques of psychiatry a subset of postmodern philosophies, most of which tend to subvert, negate, or delegitimize the Western rational-empirical tradition. Thus,the postmodern theorist Francois Lyotard denies the legitimacy of “grand narratives”—essentially, cultural myths that merely serve “. . . to mask the contradictions and instabilities that are inherent in any social organization or practice.”4 Western science, in the postmodern view, tends to be associated with coercive power and oppression.

Michel Foucault’s analysis of psychiatry is perhaps the archetypal antifoundational critique. Foucault holds that psychiatric medicine has merely fabricated a set of pseudo-objective technical terms—“delusions,” “paranoid,” “acute schizophrenia,” etc—and imposed this linguistic framework on a largely powerless group of social misfits. According to Foucault,5 these unfortunates—labeled “insane” or “mentally ill” by psychiatrists—have been denied their own “discourse” and made to conform to the collective discourse (the episteme [systems of understanding]) of psychiatric medicine. There is some degree of convergence between Foucault’s claims and those of Szasz, in so far as both castigate institutional psychiatry for its supposed coercive or authoritarian practices; however, there are substantial underlying differences between Szasz and Foucault, and Szasz does not consider his views to be antipsychiatry.

Fallacies of foundational critiques: Szasz

Szasz’s positivist view of disease is inconsistent with most of the history of clinical medicine and with many modern-day philosophers of medicine.6,7 It is only in the past century or so that physicians have begun to understand diseases in terms of their biological causes. Indeed, even today, we recognize many conditions as diseases or disorders while we have a very limited understanding of their causes or pathophysiology (eg, various forms of atypical facial pain, primary torsion dystonia, chronic fatigue syndrome).6,7 In light of the suffering and incapacity associated with these conditions, it seems perverse to argue that they will not become real diseases until we can identify specific histological or pathophysiological abnormalities. Ironically, several biomarkers or endophenotypes, such as abnormal smooth pursuit eye movements and enlarged cerebral ventricles, have been consistently associated with schizophrenia—a condition Szasz has variously characterized as a “myth” or metaphor.8

We would argue—borrowing Ludwig Wittgenstein’s term—that the “family resemblance” most characteristic of entities called diseases is the presence of intrinsic suffering and substantial incapacity.6,7 Although knowledge of a condition’s histology, pathophysiology, and etiology is extremely helpful in devising diagnostic tests and treatment strategies, such knowledge is not necessary for the ascription of disease (etymologically, “dis-ease”).

Fallacies of antifoundational critiques: Foucault

Foucault argues that all disciplines—whether scientific, legal, political, or social—operate through a system of self-legitimizing texts and linguistic conventions. Truth, therefore, cannot be absolute and claims of objectivity are impossible. More specifically, Foucault maintained that the definition and treatment of insanity constitutes a form of social control. In his classic Madness and Civilization, Foucault5 held that involuntary confinement of those deemed insane is really a coercive attempt to confine and marginalize madness.

Foucault’s analysis may shed light on how differing epistemes affect society’s management of mental illness, but it does not impugn the ontological reality of mental illness or the immense suffering it causes. Furthermore, following Foucault’s own postmodern logic, his claims regarding madness must be viewed as merely another episteme, wherein Foucault asserts his own self-legitimizing power and knowledge. Like most postmodern claims, Foucault’s argument effectively devours itself.

Finally, whereas Foucault saw himself as a kind of cultural archeologist, he is more accurately viewed as an old-fashioned moralist. Foucault’s argument with psychiatric praxis, like Szasz’s, is fundamentally hortatory: it implicitly prescribes and proscribes how people ought to behave toward their fellow citizens; eg, “We should not lock people away merely because they think or behave in ways we don’t like!” Foucault’s analysis is perfectly respectable and potentially salutary political advocacy, but it is in no sense a scientifically based critique of psychiatry. Indeed, as Ian Hacking9 observes, “Despite all the fireworks, Madness and Civilization follows the romantic convention that sees the exercise of power as repression, which is wicked.”

Diagnosis and values in medicine and psychiatry

It is a truism that psychiatric diagnosis relies on certain kinds of value judgments, and this observation is often used to marginalize psychiatry from the fold of general medicine. We acknowledge the role of values in psychiatric nosology, but we do not regard this as fundamentally different from the invocation of certain values in other medical specialties. Thus, we believe that there is no evaluative difference between the claim, “The coronary arteries should not be clogged with plaque, if you want good physical health,” and the claim, “The mind should not be bombarded with auditory hallucinations, if you want good mental health.” This is not to say that body and mind are identical constructs; that coronary artery disease and schizophrenia are closely related; or that the two conditions are experientially similar. It is simply to aver that in all of general medicine, deciding that a condition is an instantiation of disease depends on certain kinds of value judgments. But while such judgments are involved in defining health and disease, our disease categories are not merely value judgments. The determination that someone suffers from either a general medical illness or a “mental disorder” is a complex judgment and involves facts and values, as well as objectivity and subjectivity.

Consistent with the positivist tradition, psychiatric diagnosis reflects a myriad of empirical observations, such as the nature and quality of the patient’s speech, affect, thought processes, psychomotor activity, and cognitive abilities. However, subjective judgment and values determine whether putative abnormalities in these spheres amount to disease. Nevertheless, as Zachar and Kendler10 point out, “. . . values do not have to be inchoate, fuzzy, or undefinable. For example, in the DSM-IV-TR appendix, the Global Assessment of Relational Functioning Axis can be seen as an attempt to operationalize psychiatric values.”

Conclusion

Although the foundational and antifoundational traditions differ in their language and claims, both call into question the legitimacy of psychiatric diagnosis and treatment. To this extent, the rubric of antipsychiatry is probably warranted for both. We have argued that both critical traditions are founded on several misapprehensions regarding the nature of disease, the role of values in determining the presence of pathology, and on supposed differences between psychiatry and the other specialties within general medicine.

In order to defend itself—and, equally important, to reform itself—psychiatry must understand the nature of the arguments arrayed against it. Not all such criticisms are antipsychiatry and the profession must remain open to reassessment of its diagnostic methods and categories. Furthermore, as many critics would insist, psychiatric practice must take care to protect the civil liberties and ensure the informed consent of those it treats. However, neither psychiatrists nor the general public should be misled or intimidated by psychiatry’s more vituperative critics, whether of the foundational or antifoundational stripe. Neither group adequately recognizes the immense suffering and incapacity associated with psychiatric illness, and despite their humanitarian pretenses, neither group provides a demonstrably effective and humane alternative to psychiatric treatment.